About this role:

Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

**This job is open to California residents only.**

ESSENTIAL FUNCTIONS
Job Function & Responsibilities
• Investigate, analyze, and resolve highly complex provider disputes involving reimbursement methodologies, contractual interpretation, regulatory requirements, and claims adjudication.
• Serve as a subject matter expert by providing technical guidance and support to Provider Dispute Resolution Analysts regarding dispute research, claim adjudication, payment methodologies, and resolution activities.
• Research complex claims, payment history, benefits, authorizations, provider contracts, reimbursement methodologies, and supporting documentation to determine appropriate dispute resolution.
• Assist in resolving escalated provider disputes and collaborate with internal departments to facilitate timely and accurate resolution of complex provider payment issues.
• Identify recurring provider dispute trends, payment discrepancies, claim processing defects, and operational issues, making recommendations for corrective actions and process improvements.
• Perform quality reviews of provider dispute work and provide coaching and feedback to promote accuracy, consistency, and regulatory compliance.
• Assist with onboarding, training, and mentoring new Provider Dispute Resolution staff while serving as a technical resource for the department.
• Monitor changes in regulatory requirements, provider contracts, reimbursement methodologies, and organizational policies to ensure consistent application within the Provider Dispute Resolution function.
• Prepare reports, analyses, and recommendations related to provider disputes, payment trends, operational performance, and compliance activities.
• Participate in cross-functional meetings and collaborate with Claims, Configuration, Provider Relations, Finance, Compliance, Information Technology, and other departments to resolve provider payment issues and improve operational performance.
• Support departmental initiatives focused on improving provider experience, operational efficiency, payment accuracy, and regulatory compliance.
• Perform other duties as assigned.

MINIMUM QUALIFICATIONS
Education & Experience:
• High School Graduate or General Education Degree (GED
• Knowledge of:

• Medi-Cal, Medicare, and D-SNP programs, including eligibility, benefits, and managed care operations.
• Medical billing and coding methodologies, including CPT, HCPCS, ICD-10-CM, ICD-10-PCS, revenue codes, and UB-04/CMS-1500 claim forms.
• Claims adjudication principles, encounter reporting requirements, provider reimbursement methodologies, and health plan operational workflows.
• Coordination of Benefits (COB), Third Party Liability (TPL), and standard claims processing practices.
• State and federal healthcare regulations applicable to managed care organizations, including Medi-Cal, Medicare (CMS), and Department of Managed Health Care (DMHC) requirements.
• Provider contracting concepts, Division of Financial Responsibility (DOFR), reimbursement methodologies, and health plan contractual obligations.
• Claims processing systems, encounter processing concepts, and Microsoft Office applications.

KNOWLEDGE, SKILLS & ABILITIES
Preferred Qualifications:
• High School Diploma or General Education Degree (GED) required.
• Associate's or Bachelor's degree in Business Administration, Healthcare Administration, Finance, or a related field preferred.
• Five (5) years of progressively responsible experience in healthcare claims processing, provider dispute resolution, claims analysis, provider reimbursement, or a related managed care or health insurance environment.
• Experience researching and resolving highly complex provider disputes, claims adjudication, reimbursement, contractual interpretation, or provider payment issues.
• Experience providing technical guidance, mentoring staff, or serving as a subject matter expert preferred.
• Medi-Cal, Medicare, or Medicaid managed care experience strongly preferred.
• An equivalent combination of education, training, and experience that demonstrates the knowledge, skills, and abilities to perform the essential functions of the position may be considered.

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

The estimated pay range for the position is:
$38.06 - $53.29
The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.
5NE00